Description: Dr. Friedberg describes his technique of minimally invasive anesthesia using propofol and ketamine in cosmetic, office-based procedures. The book also includes brief descriptions of other anesthetic techniques for cosmetic surgery as well as a nice description of contemporary medicolegal concerns surrounding anesthetics given in an office-based setting.

Purpose: The purpose of the book is to introduce anesthesiologists to the author's technique of intravenous sedation using propofol and ketamine titrated to the BIS reading for office-based anesthetics. The result is a clear presentation of the technique and a description of how to optimize its effectiveness.

Audience: The book is directed at all anesthesiologists who provide intravenous sedation, as well as to anesthesiologists who believe that some of the cases for which they currently give a general anesthetic could be better treated with a titrated MAC. The author is a well-known expert in the field who has modified and refined his technique over his 15 years in an office-based practice.

Features: The technique of minimally invasive anesthesia is presented well. A detailed section covers regional blocks for facial surgery, but alternative techniques for cosmetic surgical anesthesia get less exhaustive, though adequate, coverage.

Assessment:The book is appropriate for practitioners interested in using this propofol-ketamine MAC technique. Many tips and suggestions are offered to help anesthesiologists with less experience with the technique optimize their anesthetics.

Reviewer: David B. Glick, MD, MB
University of Chicago Pritzker School of Medicine

It is difficult to perform surgery without anesthesia, so all plastic surgeons have some interest in this topic. Dr. Friedberg has specifically excluded oral and intravenous sedation given or directed by the surgeon; the book deals exclusively with anesthesia given and directed by an anesthesiologist. The book is written by and for anesthesiologists, with a primary emphasis on Dr. Friedberg’s approach of “Minimally Invasive Anesthesia.” This technique is a combination of premedication with clonidine followed by bispectral index (of EEG) monitoring of a propofol-ketamine intravenous anesthetic. His goal is to give the least amount of anesthesia to achieve sedation and amnesia. He believes that this leads to a faster recovery and discharge as well as a lower incidence of nausea and vomiting. An interesting component is the need for the surgeon to provide adequate local anesthesia. His admonition to anesthesiologists that they will not have success with his technique without having a working relationship with their surgeon, one that allows them to let the surgeon know that the patient needs more local anesthesia, provides some insight into the view an anesthesiologist has of surgeons and surgery. It is a reminder that any anesthetic technique that attempts to limit intravenous or inhaled agents is dependent on achieving local anesthesia. To this end, there are good chapters on lidocaine toxicity and nerve block techniques in the head and neck. Chapters on preanesthetic assessment and psychological aspects of cosmetic surgery should also interest plastic surgeons and are worth reading if you find that you have access to this text. Other chapters had little to offer a surgeon other than the issues, viewpoint, and understanding that anesthesiologists have when providing anesthesia for outpatient surgery.

This book is a worthwhile read for anyone who has a strong interest in the anesthetic management of outpatient surgery. The take-home message is that if you would like your patients to receive less medication, give them more or better local anesthetic. You could team up with your anesthesiologist to provide this if you have a working relationship with him or her. If you believe that surgery is surgery and anesthesia is anesthesia, this book is not for you.

This is a book written by office surgery–based anesthesiologists for office-based anesthesiologists. It is generally approachable, however, and there are some pearls in here for dermatologists using anything other than only local anesthesia.

The goal of the book is laudable, safer methods of anesthesia for cosmetic procedures. With use of methods described in this book, it is possible to perform almost any cosmetic procedure without the use of general anesthesia, although a chapter on general anesthesia is included. The book wanders somewhat from this goal including an unrelated chapter on propofol for military and mass casualty anesthesia.

There is a chapter devoted to lidocaine toxicity. In it the author (Adam Dorin) points out that deaths from lidocaine toxicity have occurred by the hands of both dermatologists and plastic surgeons without supporting references. Although this may be true, the number of deaths by plastic surgeons must be manyfold greater than that of dermatologists. Surprisingly, the authors support the use of dilute megadose lidocaine for liposuction. There is no separate chapter on tumescent anesthesia, however, because the author unashamedly admits to not covering techniques employed by the operating surgeon.

Interestingly there is a chapter on the business of office-based anesthesia and subheadings on self-promotion and who’s the competition? Surprising to hear from an anesthesiologist, after hearing them explain at state medical board hearings that they are currently overwhelmed with work and only testify to restrict office anesthesia for the patient’s good.

Most interestingly, there is an entire chapter devoted to the ‘‘politics’’ of office-based anesthesia. This chapter would have more accurately been titled ‘‘controversies about safety of office-based anesthesia.’’ The author does an evenhanded job of reporting on the existing literature, repeatedly referencing articles published in this journal (in contrast to the plastic surgeons). The authors are reluctant to point out, however, that more than 90% of the cosmetic surgery deaths in Florida over the past several years of mandatory data collection have occurred at the hands of plastic surgeons (presumably their number one employer).

All in all it is a fast read that is mostly accurate, and I cannot argue with the editor’s quote in the introduction: ‘‘Sadly what remains an absurd situation is that it is acceptable to have a death from a pulmonary embolism following an abdominoplasty in a hospital or ambulatory surgery center (ASC) setting but not the exact same outcome in office-based setting. This is clearly not in the interests of public safety. The emerging hypocrisy is that the hospital and ASC lobbies in Florida (and others to follow) have persuaded the legislatures to mandate reporting of all mortalities from office-based cosmetic surgery while remaining exempt from the same requirement. ALL deaths from elective cosmetic surgery should be subject to the same reporting and scrutiny as those in the office-based setting.’’ Amen.

Anesthesia in Cosmetic Surgery, edited by Barry L. Friedberg is a comprehensive textbook for those who provide anesthesia services to patients undergoing cosmetic surgery. While much of its focus is on anesthesia for office-based cosmetic surgery, the scope is sufficiently broad to cover hospital-based practices, pediatrics, and related topics such as regional anesthesia.

Laid out in three distinct sections, the book is well organized. The first section thoroughly directs the practitioner through the specific practice of propofol-ketamine (PK) intravenous anesthesia. Dr. Friedberg painstakingly elucidates the "do’s" and "don’t’s" of his "minimally invasive anesthesia" (MIA) technique. He strongly recommends that the anesthesiologist develop a close working relationship with the surgeon, and that patients be carefully selected for these extensive and often lengthy procedures. At times, the author is self-promoting in suggesting that the benefits of MIA (a 0.5% incidence of postoperative nausea and vomiting) outweigh all other concerns. The recipe is somewhat formulaic. The author states without references that patients weighing between 90 and 250 pounds have an approximately equal number of NMDA receptors, and that therefore they all should receive the same 50-mg dose of ketamine at the onset of "minimally invasive anesthesia."

From the perspective of patient safety, one must be wary of Dr. Friedberg’s suggestion that 2000 mg of dilute lidocaine represents an appropriate dose for breast augmentation. The fact that 100 sequential patients received this dose without any adverse outcomes does not provide statistically sound evidence that the technique is safe. Fortunately, a later chapter by Dr. Adam Dorin succinctly reviews the safety issues surrounding megadose lidocaine for tumescent liposuction and body contouring. Dr. Dorin quotes conventional doses and reviews the toxic plasma levels and their clinical manifestations. Typical dilution quotients, peak serum levels, and pharmacokinetics are presented for doses as high as 35 mg/ kg! In these cases, total epinephrine doses may reach 5 mg, again emphasizing the need for careful patient selection. The second major section is entitled "Alternative Anesthesia Approaches in Cosmetic Surgery." The methods presented are neither unique nor alternative to most practicing anesthesiologists. They primarily resemble the typical practice of hospital-based anesthesia and are alternative only in the sense that they differ from Dr. Friedberg’s MIA technique. Perhaps a better title for this section would be "Non-MIA Anesthesia for Cosmetic Surgery." In this regard, Dr. David Barinholtz offers a refreshing look at intravenous general anesthesia. In contradistinction to the editor, Dr. Barinholtz does not hesitate to use opioids when clinically indicated. He accurately points out that many plastic surgeons are reluctant to infiltrate additional local anesthetics once the surgical procedure has started. In addition, he discusses the appropriate use of general anesthesia with muscle relaxation during abdominoplasty. There is also a thorough review of the indications, benefits, and risks of spinal, epidural, paravertebral, and intercostal blocks during cosmetic surgery. It is well referenced, and includes a discussion of the ASRA guidelines for patients receiving anticoagulant therapy. Finally, this section covers general inhalation anesthesia for cosmetic surgery and includes a review of risk stratification for perioperative thromboembolism.

The final section entitled "Other Considerations in Cosmetic Surgery" reviews preoperative patient assessment and selection. It contains a superficial review of common diseases, which seems more suitable for the lay public rather than for anesthesiologists. Highlights include a concise presentation of herbal medicines and a section dealing with psychiatric disease in cosmetic surgery. The discussion of body dysmorphic disorder is cogent and dispels many of the common myths associated with cosmetic surgery.

The last two chapters identify the current controversies surrounding performance standards in cosmetic surgery and discuss the various accreditation agencies that oversee freestanding surgical centers, hospitals, and office-based practices. There is a clear definition that "office-based surgery" refers only to procedures performed in private physicians’ offices; an important point is made that these offices are usually not licensed or regulated by the states in the same manner as hospitals and freestanding surgical centers. The authors clearly favor accreditation-based systems over legislative regulations. Nonetheless, they believe that the practice of anesthesia in an office-based setting can be safe.

The text is easy to read. Although generally well written, it suffers from a lack of editorial oversight. The authors and editor are self-promoting at times, and there are multiple typographical errors, inconsistencies, and factual errors. Typical examples include labeling "emergence" as "emergency" on a BIS tracing (page 30), giving a case history for a rhinoplasty and subsequently referring to patient immobility "for injection of her breasts" (page 40), "sermatologic" surgeons (page 208), and a liposuction mortality rate of "19 in 1,000" (page 161). Additionally, there are occasional major errors such as categorizing halothane as an ether rather than an alkane (page 113). Despite these shortcomings, the overall intent of the individual chapters remains clear.

The text is a suitable addition to the library of those who anesthetize patients for cosmetic surgery. The reader is urged to use the described techniques as guidelines rather than de facto rules and to disregard the bravado of the editor. Also, keep in mind that the dosage guidelines for local anesthetic are "generous." Putting these issues aside, the textbook serves as a useful primer in the practice of anesthesia for cosmetic surgery and deserves a place on one’s subspecialty bookshelf.

I saw your article in July 2007 Cosmetic Surgery Times.
I immediately ordered your book.
I got it a few days ago.
I’m reading it for the second time, its great!
Thank you and thank you for writing this book.